Anger

Frank

G: As a result of his mental illness and substance abuse issues, Frank has trouble managing his anger. I met with him today to explore ways he can control his temper and resolve problems with others more effectively, and to increase his motivation to learn new skills.

G: As a result of his mental illness and substance use, Frank has trouble controlling his temper and often gets into heated arguments with others. I met with him today to continue working with him on ways of managing his anger.

I: Discussed whether anger was an effective way of getting others to do what client wanted them to. Explored consequences of using anger to control and intimidate others. Identified several undesirable consequences such as people avoiding client and becoming emotionally distant; replacing the client in their lives with "nicer people"; being less willing to do favors for him; kicking him out of places he lived; and firing him from jobs. Began discussion of more effective techniques client can use to get what he wants and needs.

I: Resumed discussion of techniques client can use to get what he wants and needs without becoming aggressive towards others. Asked client to think about what he could do differently in the future. Explored ways client could decrease or eliminate feelings of anger, such as taking a time out, exercising, venting to a close friend, and taking responsibility for his own role in conflicts.

I: Discussed the resources and sources of support client used when he was feeling angry. Worked with client to expand his range of choices to include calling a former roommate, going to the gym, venting to a trusted friend or family member, and writing his feelings down in a journal.

I: Continued discussion of ways client can reduce feelings of anger. In today’s session we focused on things client could reduce or eliminate from his life that increased his anger. Client identified "hanging out with negative people and dwelling on the past" as behaviors that increased his anger, that he could reduce or eliminate.

I: Discussed the value of compromise in resolving conflicts and reducing anger. Explored conflicts client has had recently that might have been resolved more quickly if he had been willing to make small compromises. Role-played a situation involving the client’s interaction with a housemate, using small concessions to reach an agreement with that person.

I: Discussed the importance of expressing anger rather than bottling it up inside. Linked a recent outburst client had to his reluctance to express disagreement over a new rule implemented at his sober living home. Modeled the use of "I" statements and expressing disagreement without the use of threats, insults, or shouting. Role-played assertive communication with client.

I: Reviewed steps for letting go of anger including taking responsibility for one’s self; not taking responsibility for the behavior of others; engaging in positive self-talk; developing better self-esteem; and creating a support system that encourages positive changes. Helped client come up with positive alternative responses to replace older "angry" ones.

I: Resumed discussion about ways client can reduce angry outbursts. Focused on the physical responses client experiences as his anger escalates, from the earliest signs (changes in his breathing, tightness in his stomach, and trouble sleeping) to the later signs (raising his voice, shouting, interrupting people, and hitting or breaking things). Discussed the benefits of expressing feelings at an earlier stage of anger.

I: Continued discussion from last week about the importance of recognizing signs of escalating anger and expressing feelings early. Reviewed the skill of using "I" statements, then role-played with client to demonstrate how several different situations he encounters could be handled without the use of insults or threats.

I: In prior sessions, we discussed the importance of expressing feelings in the early stages of anger, rather than holding feelings inside and increasing the chances of having an angry outburst later on. Today, we focused on the value of listening to what others have to say and taking the time to understand their points of view. Reviewed techniques for doing this effectively, such as being present in the moment and listening without evaluating.

R: Client was responsive and engaged.

R: Client recognized the benefits of learning to control his temper, but had trouble focusing on his own behavior instead of the behavior of others.

R: Client said, "_________________".

R: Clt was cooperative and willing to learn new skills, but had trouble recognizing how his own behavior had contributed to problems he had with others.

P: Will continue working with client on learning to manage his anger.

P: Will continue teaching client anger management skills.

P: Plan is to continue working with client on accepting responsibility for his own behavior, recognizing the benefits of change, and learning new ways of managing conflicts with others.

Jean

G: Due to her mental illness and substance use, client has trouble controlling her anger. Her angry outbursts have caused problems in multiple areas of her life. I met with her today to work with her on this issue, and to increase her motivation to change.

G: As a result of her MI and SUD issues, client has trouble controlling her temper and often gets into heated arguments with others. I met with her today to continue working with her on ways of managing her anger.

I: Educated clt on the difference between anger and aggression. Explained that anger has a purpose and that it is okay to feel angry. Aggression on the other hand is behavior we choose to engage in as a response to anger. Explained that there are other options, besides aggression, that can lead to better outcomes.

I: Last week I educated clt on the difference between anger and aggression. Briefly reviewed what we learned in that session, then explored incidents where clt has lost her temper in order to increase her awareness of the physical responses and sensations she experiences as her anger begins escalating, from the earliest signs (changes in her breathing, tightness in her stomach, feeling flushed, etc.) to those she experiences as her anger increases (e.g., interrupting people more often than usual, raising her voice, assuming an aggressive posture). Purpose is to help her recognize physical signs of escalating anger as early as possible so she can disengage or implement calming strategies that I plan to begin teaching her next week.

I: Reviewed signs of escalating anger that we identified last week. These are sensations and behaviors clt experiences, which may not be visible to others, as she begins to escalate and her risk of having an angry outburst increases. Then we worked to identify things clt can do when she recognizes these signs, such as slowing things down, "buying time", focusing on her breathing, inhaling slowly and deeply, and disengaging if tension continues to escalate. Modeled breathing deeply and how to disengage in a tactful way (e.g., saying "I need time to think about this").

I: Reviewed what we covered in our prior 3 sessions -- early warning signs that clt experiences when she is becoming increasingly angry, such as patterns of behavior or physical sensations, and things she can do when she becomes aware of these signs. Today I modeled the use "I" statements, such as "I feel disrespected when that happens" instead of "You’re disrespectful". I then did role-reversal with clt, expressing anger in an accusatory way ("You don’t care about me") and challenging her to express the same feeling with an "I" statement ("I don’t feel cared about by you"). I also modeled how several different situations she encounters could be handled without the use of insults or threats.

I: Engaged clt in a discussion about anger and whether aggressive behavior was an effective way of getting others to do what she wanted. Identified consequences of using anger to control and punish people. Clt was able to come up with several undesirable consequences such as people avoiding her and becoming emotionally distant; replacing her in their lives with people who were easier to get along with; being less willing to do favors for her; and kicking her out of places she has lived. Began a discussion of more effective techniques clt can use to get her needs met.

I: Resumed discussion of techniques clt can use to get what she wants and needs without cutting others off mid-conversation or raising her voice and becoming aggressive. Asked her to think of situations where she had abruptly ended the conversation leaving a problem unresolved, in some cases not speaking to the other person again for weeks or months, and consider what the eventual outcome was. Purpose was to raise her awareness of the fact that regardless of what she feels in the moment, the long-term outcome is almost always negative -- the loss of companionship, emotional support, opportunities to participate, etc.

I: Last week I worked to raise clt's awareness of the fact that regardless of how she feels in the moment, the long-term result of behaving aggressively is almost always negative. With this in mind, we brainstormed together to generate ideas on how she could have handled those situations differently. Reviewed our best ideas (asking for time to think, taking deep breaths) and encouraged her to try applying one or both of them to similar situations she encounters in the future.

I: Today we discussed techniques that clt could use to decrease or eliminate angry outbursts. I explained a number of different techniques to her, such as journaling about her feelings, writing an angry letter and then throwing it away instead of sending it, venting to a trusted friend or someone who isn’t connected to the person or persons she is angry with, getting more physical exercise, and accepting her share of responsibility for conflicts she has with others.

I: Last week we talked about ways clt can manage feelings of anger without losing her temper and doing something she later regrets. One of the techniques we talked about was writing an angry letter and then throwing it away instead of sending it. Today I expanded on that idea, explaining to clt that she could continue composing such a letter for several days or even weeks if she wants, getting the feelings out of herself and onto paper, adding and changing things in preparation for the final draft, which she will throw away. I explained that buying time this way can help her see things more objectively, possibly from the other person's point of view, and avoid saying things she later regrets.

R: Client was responsive and engaged.

R: Client recognized the benefits of learning to control her temper, but had trouble focusing on her own behavior instead of the behavior of others.

R: Client said, "_________________".

R: Clt was cooperative and willing to learn new skills, but had trouble recognizing how her own behavior had contributed to problems she had with others.

P: Will continue working with client on learning to manage her anger.

P: Will continue teaching client anger management skills.

P: Plan is to continue working with client on accepting responsibility for her own behavior, recognizing the benefits of change, and learning new ways of managing conflicts with others.

Joseph

G: As a result of his mental illness and substance use, Joseph has trouble managing his temper. His angry outbursts lead to problems in multiple areas of his life. Due to lack of insight, however, he denies having problems with anger and attributes his outbursts to the behavior of others.

G: As a result of his mental illness and substance use, Frank has trouble controlling his temper. Although his angry outbursts contribute to impairments in multiple areas of functioning, he denies having a problem and blames his behavior on others. I met with him today to continue raising his awareness of the need for change, and offering suggestions on how to do it.

I: Clt expressed no interest in learning anger management techniques, so I engaged him in a discussion about the pros and cons of having angry outbursts, with the goal of increasing his awareness and motivation to change. On the plus side, he identified "getting it out of myself" (releasing pent-up tension), "getting their attention", and making people think twice about bothering him again. On the negative side, he was able to see that these outbursts were toxic to his relationships if they occurred repeatedly, and that regardless of how they made him feel at the time, they ultimately left him with fewer and fewer friends. He was unable to recall any situation where a calmer approach would not have resulted in a better long-term outcome.

I: Reviewed our discussion from last week about the pros and cons of having angry outbursts, focusing on the negatives clt identified and how they appeared to outweigh the positives. Then we explored how clt could recognize a situation in which he was escalating towards an angry outburst. By looking back at a number of recent situations, clt was able to identify several things he felt or did that seemed to precede an angry outburst, such as his skin feeling hot, clenching his fists, raising his voice, interrupting more often, and getting "tunnel vision". I praised clt for his willingness to examine his own behavior and talk with me about it.

I: Last week I noted that clt responded positively to praise, so I began this session by framing "willingness to change" as sign of strength and courage, then praised clt for having this willingness despite the fact that he has not actually demonstrated it yet. Reviewed our last two sessions in which we identified how he could benefit by controlling his temper, and how he would know when it was time to take action (i.e., to either disengage or start using a de-escalation technique). Today I modeled disengagement for him (e.g., saying I needed to use the restroom, or that I needed time to think, or time to check something out). Demonstrated how he could do this tactfully and give himself time to calm down and regroup without making a scene or losing face, then resume the conversation when he felt ready.

R: Client would not acknowledge having a problem with anger, but was cooperative and willing to learn the skills I showed him.

R: Client was willing to practice the techniques I showed him, but continued to blame others for his angry outbursts.

R: Client said, "_________________".

R: Clt was cooperative and willing to learn new skills, but had trouble recognizing how his own behavior contributes to problems he has.

P: Will continue working with client on learning to manage his anger.

P: Will continue teaching client anger management skills.

P: Will continue working to raise client's awareness of the need for change, and teach him more effective ways of managing and expressing his emotions.